1477748085 NPI number — LARRY JAMES SCHLAUDERAFF O.D.

Table of content: LARRY JAMES SCHLAUDERAFF O.D. (NPI 1477748085)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477748085 NPI number — LARRY JAMES SCHLAUDERAFF O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCHLAUDERAFF
Provider First Name:
LARRY
Provider Middle Name:
JAMES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477748085
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
202 NW 1ST AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55744-2703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-326-0358
Provider Business Mailing Address Fax Number:
218-326-0566

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 NW 1ST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55744-2703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-326-0358
Provider Business Practice Location Address Fax Number:
218-326-0566
Provider Enumeration Date:
09/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  MN2415 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3C837EY . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3C837EY . This is a "BLUE PLUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3C838SC . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3C838SC . This is a "BLUE PLUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2200897 . This is a "MEDICA GR" identifier . This identifiers is of the category "OTHER".
  • Identifier: HP29720 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4C427EY . This is a "MINN CARE BLUE PLUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1008835 . This is a "COPORATE BENEFIT SERV" identifier . This identifiers is of the category "OTHER".
  • Identifier: 974251008835 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: U33589 . This is a "FIRST PLAN BLE" identifier . This identifiers is of the category "OTHER".
  • Identifier: U33589 . This is a "FIRST PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 611825900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: U33589 . This is a "EYE MED" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com